What is the treatment for impetigo?

Treatment for Impetigo

Topical mupirocin 2% ointment is the first-line treatment for limited impetigo, while oral antibiotics such as clindamycin or first-generation cephalosporins are recommended for extensive disease. 1

Treatment Algorithm

1. Assess Extent of Disease

• Limited disease (few lesions in a localized area):
  • Use topical antibiotics
• Extensive disease (multiple lesions or widespread):
  • Use oral antibiotics
  • Consider systemic therapy for outbreaks affecting several people to decrease transmission 1

2. First-Line Treatment Options

For Limited Disease:

• Topical mupirocin 2% ointment applied three times daily for 5-7 days 1, 2
  • Clinical efficacy rates of 71-93% in clinical studies 2
  • Effective against both Staphylococcus aureus and Streptococcus pyogenes 1, 2
  • Alternative topical options: retapamulin and fusidic acid 1

For Extensive Disease:

• Oral antibiotics for 7-10 days: 1
  • Clindamycin (300mg three times daily) - excellent coverage against MRSA and streptococci
  • First-generation cephalosporins (e.g., cephalexin)
  • Amoxicillin/clavulanate

Special Considerations

For Suspected/Confirmed MRSA:

• Trimethoprim-sulfamethoxazole (160-800mg twice daily for 7-10 days)
  • Highly effective against MRSA
  • Important caveat: Inadequate streptococcal coverage; may need to combine with a beta-lactam if streptococcal infection is suspected 1
• Clindamycin (300mg three times daily for 7-10 days)

For Penicillin-Allergic Patients:

• Clindamycin
• Macrolides (e.g., erythromycin)
• Doxycycline (for patients >8 years old) 1

Treatment Response and Follow-up

• Evaluate clinical response within 48-72 hours of starting therapy 1
• Expected resolution within 7-10 days with appropriate treatment 1
• If no improvement within 3-5 days:
  • Consider bacterial culture and sensitivity testing
  • Evaluate for alternative diagnosis
  • Consider need for intravenous antibiotics 1

Prevention and Hygiene Measures

• Keep lesions covered when possible
• Use separate towels and linens
• Practice good hand hygiene
• Avoid sharing personal items
• Promptly identify and treat cases to prevent spread 1

Common Pitfalls to Avoid

1. Failure to consider MRSA in recalcitrant cases 1
2. Using penicillin alone, which has been shown to be inferior to other antibiotics 1, 3
3. Inadequate treatment duration 1
4. Relying solely on topical therapy for extensive disease 1
5. Using tetracyclines in children under 8 years due to risk of inhibiting bone growth 1
6. Using topical disinfectants which are inferior to antibiotics 4, 5
7. Not addressing underlying conditions that may predispose to recurrent infection 1

Evidence Strength

The recommendation for topical mupirocin is supported by multiple clinical studies showing efficacy rates of 71-93%, with 100% pathogen eradication in some studies 2. Topical antibiotics have been shown to be superior to placebo (RR 2.24,95% CI 1.61 to 3.13) and at least as effective as oral antibiotics in limited disease 4. For extensive disease, oral antibiotics are preferred, with clindamycin showing excellent coverage against both MRSA and streptococci 1.